Don’t Gamble with Norovirus
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Don’t Gamble with Norovirus. Kristen Obbink, DVM, MPH Eric Bradley, MPH, REHS, CP-FS, DAAS 2014 NEHA AEC - Las Vegas, NV. What it is, What it isn’t. Calicivirus with 6 Genogroups Genogroups I, II, and IV cause human illness Environmentally stable

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Don’t Gamble with Norovirus

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Don’t Gamble with Norovirus

Kristen Obbink, DVM, MPH

Eric Bradley, MPH, REHS, CP-FS, DAAS

2014 NEHA AEC - Las Vegas, NV


What it is, What it isn’t

  • Caliciviruswith 6 Genogroups

    • Genogroups I, II, and IV cause human illness

  • Environmentally stable

    • Resists heating to 60o C & able to survive freezing

  • AKA - “Food Poisoning” or “Stomach Flu”

  • Not related to the influenza virus


What does it do to you?

  • Commonly causes diarrhea, vomiting, nausea, stomach cramps

  • Other symptoms include fever, headache, body aches

  • Usually no long-term health impacts

  • Dehydration most common complication


How does it spread?

  • Fecal/Oral

    • Eating or drinking contaminated food items

    • Touching contaminated surfaces or objects and then putting your fingers in your mouth, or

    • Having contact with someone who is infected


How does it spread? (Cont…)

  • Aerosol

    • Being near someone who is vomiting


True or False Questions

  • You can only get Norovirus once in your life and then you are immune


True or False Questions

  • You can only get Norovirus once in your life and then you are immune.

    • False

      • Many different types of noroviruses

      • Immunity is short-lived


True or False Questions

  • You can spread Norovirus even after your diarrhea stops


True or False Questions

  • You can spread Norovirus even after your diarrhea stops

    • True, see the next slide


When can you spread it?

  • Virus is in stool before symptoms start

  • Virus can stay in stool for 2 weeks or more after symptoms stop

  • Most contagious when sick with symptoms and during the first three days after recovery


Norovirus Trivia

  • 1929 - First recognized outbreaks of viral gastroenteritis termed “winter vomiting disease”

  • 1940 - Demonstrated that pooled stool filtrates obtained from patients in an institutional outbreak could infect volunteers

  • 1968-CDC investigated vomiting disease in an elementary school in Norwalk, OH


Top pathogens contributing to foodborne illnesses, hospitalizations and deaths in US (2011)


Cruise Ships…Schools…Gatherings…Long Term Care Facilities

  • Transmits easily when people are in close contact

  • Very low infectious dose


Infectious Dose

  • Norovirus: 10-100

  • Shigella: 10-100

  • Salmonella: 105 - 108

  • Campylobacter: 104 – 106

  • E. coli: 108


Investigating Norovirus Outbreaks

  • Collect illness information

  • Get a diagnosis – COLLECT STOOL SPECIMENS

  • Focus on prevention, educate everyone


Collect illness information

  • Onset of symptoms

    • Incubation typically 24-48 hours

  • Symptoms

    • Diarrhea, vomiting, nausea, stomach cramps

    • Vomiting more common in children

  • Duration of illness

    • Usually 24-48 hours

  • Usually see high attack rate & 2° spread


Get a Diagnosis

Collect stool specimens

  • Offer to drop off and pick up stool kits, if possible

  • Send to appropriate laboratory (some labs are unable to test for Norovirus)

  • Label vials and fill out appropriate paperwork


Diagnosing Norovirus

  • Polymerase chain reaction (PCR)

  • Takes ~4 hours to complete

  • High sensitivity

    • Detects concentrations as low as 10 viral particles

  • Cannot detect all small round viruses, so negative test is not always conclusive


Prevention is KEY!!

  • Noro Cleaning Guidance

    • In the home

    • In restaurants/facilities

  • Stay home when sick!!

    • If you are out and about, you are spreading norovirus

    • Good hand hygiene

  • Don’t cook for others…

    • Don’t cook for others until at least 48 hours after symptoms cease


Hand Gels and Norovirus

  • Scientific uncertainty over effectiveness of alcohol-based hand gels against norovirus

  • Always wash hands with soap and warm water when able

  • Alcohol-based hand gels should only be used in situations where soap and warm water are not available


Guidance documents available for many situations…

  • Long term care guidance

  • School /childcare guidance

  • Healthcare setting guidance

  • Food handlers


General Guidance for Childcare Facilities

  • Children or staff with diarrhea and/or vomiting:

    • Exclude until 24 hrs after diarrhea & vomiting cease

  • Staff who handle food and have diarrhea and/or vomiting:

    • Excludeuntil 48 hrsafter diarrhea & vomiting cease

    • Most staff members in child care programs are considered food handlers

  • Educate staff, parents& children on proper hand washing technique


Outbreak Guidance for Childcare Facilities

  • Consider providing guidance on prevention of norovirus to parents, staff& children

  • Increase frequency of routine cleaning

    • Focus on disinfection of commonly touched areas: doorknobs, phones, etc.

    • Toys should be cleaned &disinfected daily


Outbreak Guidance for Childcare Facilities (cont…)

  • Ensure restrooms are adequately stocked with soap, paper towels, &warm running water

  • Request stool specimens from 3-5 of the ill individuals to confirm cause of the outbreak


General Guidance for Schools

  • Students and staff with diarrhea and/or vomiting:

    • Exclude until 24 hrsafter diarrhea & vomiting cease

  • Any staff/student who handles food &has diarrhea and/or vomiting:

    • Exclude from food handling activities until 48 hrsafter diarrhea &vomiting cease

  • Educate staff members, parents, &students on proper hand washing technique


Outbreak Guidance for Schools

  • Consider providing guidance on prevention of norovirus to parents, staff & children

  • Increase frequency of routine cleaning

  • Temporarily stop using self-service foods for school breakfast/lunch

  • Ensure restrooms are adequately stocked with soap, paper towels, and warm running water

  • Request stool specimens from 3-5 of the ill individuals to confirm the cause of the outbreak


Guidance forCommunity Residential Programs

  • Actions taken will depend on the type of program and the level of functioning of the residents

  • General recommendations include:

    • Residents with suspected or confirmed norovirus:

      • Place on Enteric precautions until symptoms subside

    • Staff members with suspected or confirmed norovirus:

      • Exclude until 24 hrsafter vomiting and diarrhea cease


Guidance for Community Residential Programs (cont…)

  • Staff and clients with suspected or confirmed norovirus:

    • Refrain from handling or preparing food for other residents until 48 hrsafter vomiting or diarrhea cease

  • Educate staff members, residents, and visitors on proper hand washing technique


General Guidance for Hospital &Long-term Care Facilities

  • Place ill patients in private rooms or cohort ill patients in the same room

  • Consider grouping ill patients in same area or wing of facility

  • Minimize un-necessary movement of residents

  • Consider temporarily discontinuing group activities until outbreak has resolved


General Guidance for Hospital &Long-term Care Facilities (cont…)

  • Consider serving meals in resident rooms instead of dining hall

  • Educate staff members, residents, and visitors on proper hand washing techniques

  • Send all ill staff home immediately


General Guidance for Hospital & Long-term Care Facilities (cont…)

  • Staff with diarrhea and/or vomiting:

    • Exclude until 24 hrs after diarrhea & vomiting cease

    • Educate on proper hand hygiene upon returning to work

  • Patients with suspected norovirus infection:

    • Manage with standard &contact precautions with careful attention to hand hygiene practices


General Guidance for Hospital & Long-term Care Facilities (cont…)

  • Contact precautions should be used when caring for diapered or incontinent persons, during outbreaks in a facility, and when a splash could occur

  • Persons cleaning areas heavily contaminated with vomitus or feces should wear surgical masks

  • Food handlers with diarrhea and/or vomiting:

    • Exclude until 48 hrsafter vomiting & diarrhea cease


General Guidance for Hospital & Long-term Care Facilities (cont…)

  • Medical equipment used for care of norovirus-infected patients:

    • Dedicate to that patient for duration of patient’s isolation OR

    • Thoroughly disinfect when removed from patient’s room

  • Select appropriate cleaning agent based on equipment manufacturer’s recommendation for compatibility


Outbreak Guidance for Hospital & Long-term Care Facilities

  • Collect stool specimens from 3-5 patients to confirm cause of outbreak

  • Assign staff to work with well residents or sick residents, not both

    • Limit staff from moving between affected & unaffected areas of facility & limit any non-essential personnel from affected areas


Outbreak Guidance for Hospital & Long-term Care Facilities (cont…)

  • Consider limiting new admissions to affected areas until all patients are well and no new cases are occurring

  • Inform visitors about a possible disease outbreak in your facility

  • Consider limiting or stopping visitation to facility until there have been no new cases for at least 48 hrs

  • Post extra hand washing signs in various visible areas in the facility


IDPH Norovirus Outbreaks - 2012

  • Only outbreaks are reportable

  • 30 suspected or confirmed Norovirus outbreaks investigated in 2012

    • 9 long-term-care or assisted living

    • 7 restaurant

    • 6 child care/school/college

    • 4 private gathering

    • 2 hospital

    • 2 other

  • Over 660 people ill


Activity Ongoing in 2013-14

  • Activity slowing but ongoing

  • Investigated several in the last few weeks

    • Long term care

    • Private gatherings

    • Restaurants


Outbreaks

  • Restaurant

    • Hotel

  • Casino

    • Hotel / Conference Center / buffet


Restaurant Outbreak


Restaurant Outbreak


Restaurant Outbreak


Restaurant Outbreak

  • EH coordinator and Deputy Director

  • DIA Foodborne Illness Complaint Form

  • Staff


Complaint Inspection


Complaint Inspection


Complaint Inspection


Customer Interviews


Customer Interviews


Customer Interviews


Customer Interviews


Investigation


Investigation


Investigation


Investigation

  • March 20, 2012

    • Stool kits

    • Data entry


Investigation


Investigation


Investigation


Investigation


Investigation


Investigation


Employee Interviews


Employee Interviews


Conference Call

  • SCHD Staff

  • IDPH

  • DIA


EPI2000


EPI2000


Employee Interviews


Investigation

  • March 21, 2012

    • Stool kits


Investigation

  • March 22, 2012

    • Facility reopened

    • Noro confirmed

    • Employee C

    • Conference call


Restaurant OutbreaK


Restaurant Outbreak


Restaurant Outbreak


Review

  • Conference call

  • 2 groups – 67 total

  • 40 ill

    • Attack rate: 60%

  • Stool kits

  • Employee C

  • Noro cleaning

  • Case closed


Restaurant Outbreak


Restaurant Outbreak


Restaurant OutbreaK


Restaurant Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Casino Outbreak


Conference Call


Interventions


Health Department


Food Service


Conference Call


Action Plan


Action Plan


Continued Surveillance


Questions?


Kristen Obbink, DVM, MPH

Foodborne Illness Epidemiologist

Iowa Department of Public Health

Kristen.Obbink@idph.iowa.gov

515-281-6049

Eric Bradley, MPH, REHS, CP-FS, DAAS

Environmental Health Specialist

Scott County Health Department

Eric.Bradley@scottcountyiowa.com

563-326-8618


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